Hashimoto Thyroiditis

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Amelia Cantrell fromBellarmine University's Pathophysiology of Complex Patient Problems project.

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Definition/Description

Hashimoto's Thyroiditis, also referred to as chronic lymphocytic thyroiditis, is where one's immune system attacks one's theyrodi gland.¹  The inflammation that results leads to hypothyroidism.¹ Hashimoto Thyroiditis "progresses slowly over a number of years and causes chronic thyroid damage, leading to a drop in thyroid hormone levels in your blood."¹

WashingtonDeceit. Histopathology Thyroid--Hashimoto thyroiditis. Available at:http://www.youtube.com/watch?v=jx1nfcT3CCo&feature=BF&playnext=1&list=QL&index=1 [last acessed 3/3/11]

Prevalence

Hashimoto's Thyroidities "is the is the most common cause of hypothyroidism in the United States."¹  Hashimoto Thyroiditis is found most often in "middle-aged women and tends to run in families."¹  However, the disease is sometimes diagnosed in "teens and young women."²  The disease is "7 times more common in women than in men."²  

According to the Systemic Autoimmune Disease Research Center of Western New York (SADRC-WNY), the disease is "clinically evident in roughly 6% of the female population."⁴    They continue to say that "in autopsy studies, as many as 20% of females may have evidence of autoimmune thyroid injury."⁴

Characteristics/Clinical Presentation

Hashimoto Thyroiditis does not present with any unique signs and sympoms.¹  The disease "progresses slowly over a number of years and causes chronic thyroid damage, leading to a drop in thyroid hormone levels."¹  The patient may present with "a feeling of fullness in the throat" or they they may be having difficulty swallowing.² 

 Signs and Symptoms:¹

• Fatigue and sluggishness
• increased sensitivity to cold
• Consitipation
• Pale, dry skin
• A puffy face
• Hoarse voice
• An elevated blood cholesterol level
• Unexplained weight gain--ocurring infrequently and rarely exceeding 10 to 20 pounds, most of which is fluid
• Muscle aches, tenderness and stiffness, expecially in your shoulders and hips
• Pain and stiffness in your joints and swelling in your knees or the small joints in your hands and feet
• Muscle weakness, especially in your lower extremities
• Excesses or prolonged menstrual bleeding
• Depression

Without treament the signs and symptoms increase in severity and include:¹

• Goiter
• Forgetfullness
• Slowing of the thought processes
• increased depresssion

Picture of a Goiter.

http://upload.wikimedia.org/wikipedia/commons/d/de/Thyroid_cancer.jpg

 

Associated Co-morbidities

Hashimoto's Thyroiditis is often diagnosed in individuals with other autoimmune diseases.² These include:² 

• Vitiligo
• Rheumatoid Arthritis
• Addison's Disease
• Type 1 Diabetes
• Graves' Disease
• Pernicious Anemia
• Lupus
  

Medications

Levothyroxine: "man-made form of T4 hormone."²  This medication "almost always"² needs to be taken for the rest of a person's life and in the same manner each day.²
Dosage depends on:²

• Age
• Weight
• Severity of the underactive thyroid
• Other health problems
• Use of other medicines that can interact with levothyroxine

If the patient goes untreated the patient may face:²

• Infertility
• Miscarriage
• Giving birth to a baby with birth defects
• High cholesterol

Severe hypothyroid complications can "rarely lead to:"²

• Heart failure
• Seizures
• Coma
• Death

Diagnostic Tests/Lab Tests/Lab Values

Thyroid function tests can be performed.²  The tests measure one's TSH and T4 levels.²  If there is "an above normal level of TSH is a sign of an underactive thyroid."²  This is becasue as they thyroid starts to fail the pituitary galnd megins to produce and increased amount of TSH to get the thyroid to produce more thyroid hormone.²  The thyroid is able to meet the increased demands on it for a time, and therefore tests will show normal T4 levels accompianed by slighly increased TSH levels.²  This condition is referred to as "subclinical hypothyroidism."²  As time goes on, "the damaged thyroid cannot keep up, and they T4 levels will drop below normal while the TSH levels are high."² 

Another test that is perfored is the 'Antibody Test.'  This test looks for a specific antibody that is typically not found in individuals who do not have Hashimoto Thyroiditis, however, :some people have the antibodies...but have normal thyroid function.² 

The patient may also have a ultrasonogram helps to differentiate this condition from another.³

Etiology/Causes

Hashimoto Thyroiditis is caused when one's "immune system creates antibodies that damage [one's] thyroid gland."¹  The cause of the autoimmune disease is unknown, but there are some theories and factors that may play a role.

Theories:^{1 & 2}

1. Virus or bacterium trigger
2. Genetic flaw
3. Gender
4. Pregnancy
5. Too much iodine and some drugs
6. Radiation exposure

BupaHealth. How a thyroid gland can become underactive. Available at: http://www.youtube.com/watch?v=2AFiMipv63k&feature=related [last acessed 3/3/11]

Systemic Involvement

The patient may present with the symptoms listed above that mimic musculoskeletal pain.

Medical Management (current best evidence)

The patient will take the synthetic hormone for their entire life, as discussed above.¹  The physian may see the patient to check the patient's "level of TSH after a few weeks of treatment."¹  According to the Mayo Clinic, the patient's physician will most likely check their TSH level every 6-12 months.¹ 

Physical Therapy Management (current best evidence)

Physical Therapists typically do not treat patients with this disorder. However, they should know to screen for it, and they may have a patient that has Hashimoto Thyroiditis as a co-morbidity.

Alternative/Holistic Management (current best evidence)

Natural extracts such as Armour Thyroid are sometimes used.¹  They contain "levothyroxine and triiodothyronine (T-3).¹  
Concerns regarding this supplement:¹

• Balance of T4 and T3 in animals is not the same as humans
• Exact amounts of T4 and T3 can vary due to the unpredictable amount in one's blood

Differential Diagnosis

Possible differential diagnoses:³

• Euthyroid Sick Syndrome
• Hypopituitarism (Panhypopituitarism)
• Goiter
• Polyglandular Autoimmune Syndrome, Type I
• Goiter, Diffuse Toxic
• Polyglandular Autoimmune Syndrome, Type II
• Goiter, Lithium-Induced
• Thyroid Lymphoma
• Goiter, Nontoxic
• Goiter, Toxic Nodular
  

Other possible issues include:³

• Addison disease
• Alopecia areata, totalis, and universalis
• Autoimmune gastritis (pernicious anemia)
• Chronic active hepatitis
• Idiopathic hypoparathyroidism
• Polymyalgia rheumatica and giant cell arteritis
• Primary biliary cirrhosis
• Primary ovarian or testicular failure
• Rheumatoid arthritis
• Sjögren syndrome
• Systemic lupus erythematosus
• Systemic sclerosis (scleroderma)
• Type 1 diabetes mellitus9
• Vitiligo

Case Reports/ Case Studies

A. M. McGregor, D. F. Roberts, and R. Hall.  A study of triplets with Hashimoto's thyroiditis.  Postgrad Med J. 1979 December; 55(650): 894–896.  Click here for article.

A Shuper, T Leathem, A Pertzelan, B Eisenstein, and M Mimouni.  Familial Hashimoto's thyroiditis with kidney impairment.   Arch Dis Child. 1987 August; 62(8): 811–814. Click here for article.

Jan van Schaik,1 Olaf M. Dekkers,2 Eleonora P. M. van der Kleij-Corssmit,2 Johannes A. Romijn,2 Hans Morreau,3 and Cornelis J. H. van de Velde1*.  Surgical Treatment for Unexplained Severe Pain of the Thyroid Gland: Report of Three Cases and Concise Review of the Literature.  Case Report Med. 2011; 2011: 349756.  Click here for article.

G. T. Ko, C. C. Chow, V. T. Yeung, H. Chan, and C. S. Cockram.  Hashimoto's thyroiditis, Sjogren's syndrome and orbital lymphoma.  Postgrad Med J. 1994 June; 70(824): 448–451.  Click here for article.

P L Vold and P J Weiss.  Rhabdomyolysis from tourniquet trauma in a patient with hypothyroidism.  West J Med. 1995 March; 162(3): 270–271.  Click here for article.

add links to case studies here (case studies should be added on new pages using the case study template)

Resources

American Thyroid Association.  http://www.thyroid.org/

Thyroid Federation International.  http://web.thyroid-fed.org/en/

Recent Related Research (from Pubmed)

<div class="researchbox"><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1FuuOtUS4LZV89WtrngDX7XbXUiBHUpRwfCQv3V3_pAWlmhQRv%7Ccharset=UTF-8%7Cshort%7Cmax=10</rss></div>

 

References

1. Mayo Clinic Staff. Hashimoto's Disease. MayoClinic.com. February 3, 2011. Available at: http://www.mayoclinic.com/health/hashimotos-disease/DS00567/METHOD=print. Accessed: February 22, 2011.
2.  Cooper DS.  Hashimoto's Disease.  U.S. Department of Health and Human Service, Office on Women's Health.  May 18, 2010.  Available at: http://www.womenshealth.gov/faq/hashimoto-disease.pdf.  Accessed: February 22, 2011.

3.  Lee, SL.  Hashimoto Thyroiditis: Differential Diagnoses & Workup.  eMedicine from WebMD.  March 12, 2010.  http://emedicine.medscape.com/article/120937-diagnosis.  Accessed: March 7, 2011.

4.  Hashimoto Thyroiditis.  Systemic Autoimmune Disease Research Center of Western New York (SADRC-WNY).  http://www.smbs.buffalo.edu/med/wnysadrc/hashimot.htm#Hashimoto%20Thyroiditis. Accessed: March 7, 2011.